Reasons for Cancellation of Cases on the Day of Surgery–A Prospective Study

Summary Late cancellation of scheduled operations is a major cause of inefficient use of operating-room time and a waste of resources. We studied elective operating theatre bookings in general surgical discipline. On the day of surgery the intended list was noted and a list of cancellations with the reason was noted by the attending anaesthesiologist. 1590 patients were scheduled for elective surgical procedures in 458 operation rooms. 30.3 % patients were cancelled on the day of surgery. Of these, 59.7% were cancelled due to lack of availability of theatre time, 10.8% were cancelled because of medical reasons and 16.2% did not turned up on the day of surgery. In 5.4% patients, surgery was cancelled by surgeons due to a change in the surgical plan, 3.7% were cancelled because of administrative reasons, and 4.2% patients were postponed because of miscellaneous reasons. We believe that many of the on-the-day surgery cancellations of elective surgery were potentially avoidable. We observed that cancellations due to lack of theatre time were not only a scheduling problem but were mainly caused by surgeons underestimating the timeneeded for the operation. The requirement of the instruments necessary for scheduled surgical listshould be discussed a day prior to planned OR list and arranged. The non-availability of the surgeon should be informed in time so that another case is substituted in that slot. All patients who have met PACU discharge criteria must be discharged promptly to prevent delay in shifting out of the operated patient. Day care patients should be counseled adequately to report on time. Computerized scheduling should be utilized to create a realistic elective schedule. Audit should be carried out at regular intervals to find out the effective functioning of the operation theatre.


Introduction
Major hospitals invest considerable resources in main tain in g operating suites and having anaesthesiologists, surgeons and theatre staff available on an agreed schedule. However, unanticipated cancellation of scheduledoperations at the last minute, even on the morning of surgeryis of concern. In some cases, patients have even been prepared for theatre and staff is assembled and expecting to operate. Late cancellation of scheduled operations is a major cause of inefficient use of operating-room time and a waste of resources. It is also potentially stressfulwith depressing effects and costly to the patient in terms of working days lost and disruption of daily life 1,2 .
We undertook a prospective study on the day surgery cancellations in agovernment hospitalin New Delhiwith the aim to find out the causesof cancellation of cases scheduled on the day of surgery and to suggest measures for optimum utilization of operating room (OR) time.

Methods
At our hospital, all patients are evaluated in the preanaesthesia clinic wellbefore surgery and obtain PAC clearance prior to being posted for surgery. Diffi-cult cases (anticipated long surgeries or patients with poor general condition or co morbidities ordifficult airways) are shown to the concerned anaesthesiologist a day prior to surgery. The operatinglist is prepared by the surgeons, and sent to OR by afternoon.
We studied elective operatingtheatre bookings in generalsurgicaldiscipline at a large tertiary government hospital in Delhi (1542 resourced beds, 16 operating theatres) for 6 months. A cancellation on the day of intended surgery was defined asany operationthat was either scheduled on the final theatre list for that day (generated at 15:00 hours on the previous day) or was subsequently added to the list and that was not performed on that day. On the day of surgery the intended list was noted and a list of cancellations with the reason fo r cancellatio n was noted by the attending anaesthesiologist.

Results
1590 patients were scheduled for elective surgicalprocedures in 458operation rooms duringthe study period. 47.7% patients were male and rest being females. 28% of the total surgical procedures were planned laparoscopically.
Of 1590, 482 (30.3 %) patients were cancelled on the day of surgery. 288 out of 482 (59.7%) were cancelled due to lack of availability of theatre time; 52 out of 482 (10.8%) were cancelled because of medical reasons and 78 out of 482patients (16.2%) did not turn up on the day of surgery. In 26out of 482 (5.4%) patients, surgery was cancelled by surgeons due to a change in the surgical plan; 18 out of 482 (3.7%) were cancelled becauseof administrative reasons (autoclaved instruments/linens not available, instrument not available); 20 out of 482 (4.2%) patients were postponed because of miscellaneous reasons (no availability of senior surgeon for the case, ICU bed/ventilator, adequate blood products and refusal of consent by patient) (Table 1).

Discussion
The decision to postpone surgery in a patient afteradmission forsurgeryhas psychological, social, and economic implications,and is notonly basedon clinical considerations. The reported rates for day-of-surgery cancellation rates varywidely among institutions from 10-40 %. We found that 30.3 % of all scheduled elective operations in generalsurgery were cancelled on the day of surgery. Fischer reported that almost 90% of operatingroom (OR) cancellations are day-of-surgery cancellations 3 .
We believe that many of the on-the-day surgery cancellations of elective surgery werepotentially avoidable in our audit.
Jonnalagadda et al reported the reasons for cancellation of scheduled routine and emergency cases as non-availability of beds in the recovery room (15%), improper preoperative patient preparation (13%), patient not showing up (9%), and unavailability of staff (19%). They also mentioned that public patients were cancelled more frequently than private patients 4 .
Schofield et al in their study of cancellation of intended surgery at a majorhospital inAustralia reported 941 (11.9%) cancellations out of 7913theatre sessions. The reasons included no bed available (18.9%), run out of theatre time (16.1%), patientnon-arrival(10.5%), Vinukondaiah et al cited the major reasons for cancellation of cases in the general surgery OR to be lack of operating time (65.2%), emergency surgery during the elective list (13.9%), and lack of fitness (11.3%) 5 . In our institute cancellation of elective cases due to emergency cases was not a problem because of the presence of a dedicated emergency OR. But sometime, the senior surgeon is called to emergency OR for help thereby delayingor wastingroutine OR time leading to the postponement of an elective case.
Windokun et al reported that only 38% of the booked surgery was performed and the reasons for such cancellation included 'surgeons did not show up'(62%), 'surgerypostponed bysurgeons'(18%) and 'patient ill prepared for surgery'(10%) 6 .
In our study non-availability of OR time was the most common reason. We observed that cancellations due to lack of theatre time were not only a scheduling problem but were mainlycaused bysurgeons underestimating the time needed for the operation. Surgeons generally add more patients to the OTlist to reduce the waiting list and in anticipation of any unexpected cancellations. An analysis inUSA examining56,000 cases retrospectively found that 31% of lists were predictably overbooked 1 . Moreover, unforeseen anaesthetic or surgical problems may delay the planned list. The time taken for a particular surgery also depends on the skillof operating surgeon. Less experienced surgeons and trainees often take more than the expected time. For some surgeriesthe totalduration exceededthe usual surgical time due to an unexpected surgical complication, juniorsbeing taughtand allowed to do the surgery especially for laparoscopic procedures, unavailability of sterilized instruments, and technical problems in instruments.
Hsiao et al suggested having of dedicated minimally invasive surgery suites to save time in transporting of equipmentsand thusoptimizingutilizationof OR time 7 . In our audit too, one of the reasons for delay in the start of surgery was because of time required to arrange laparoscopic equipments as sometimes it was being used in the other OR.
Ogden et al reported OR time over run in 27% and reasonsmentioned wereimproper utilization of OR time and undue delay when junior surgeons/ anaesthesiologist performed the cases 8 . Pandit et al concluded that over running OR lists were the commonest cause of the cancellationof cases on the day of surgery (50% lists were overbooked and 50% over ran their scheduled time) 9 .
Late start of the OR due to absence of staff has also been reported to lead to underutilization of OR time leadingto cancellation of the cases 10 . Weinbroum et al reported that 15% of the OR time was wasted due to inappropriately prepared patients, unavailability of surgeons, insufficient OR staff, congestion of PACU, and delay in the transport to the OR 11 .
Theanaesthesia time was variableamong patients even for similar surgeries. This was probably because of patient physicalstatus, anaesthetist's expertise and technical problems. However Hussain reported that only 8% of all cancellation of cases on the day of surgery was anaesthesia related 12 .
An accurate real time based schedule should be made consideringthe expected duration ofsurgery, the availability of staff, equipments andcorrect instruments for a smooth running OR.
Medical cancellations are generally presumed to be another reasonof cancellations. Because cancellations caused by medicalproblems are especially upsettingfor patients and canbe morecontentious for membersof themedicalstaffthese cancellationsmay be more memorablethan othertypes ofcancellations. Inadequate preoperative medicaloptimization was another important reason for cancellation of cases in our study. The major reasons were hypertension, recent onset respiratory tract infections, uncontrolled diabetes and an acute onset cardiovascular abnormality. Some cancellations due to failure to comply with the preoperative orders and the development of a medical illness can be m in im ized b y a preoperative visit b y the anaesthesiologist and the surgeon a day prior to scheduled surgery 3 .
Providing morebeds orquarantiningbedsfor surgicalpatients is one component of an improved system but will be insufficient unless all sources of problems receive attention. Robb et al reported that 31% of the cancelled case for the elective procedures were postponed because of "No Bed' status 13 .
Last-minute cancellation due to failure of a patient to present is especially difficult to resolve. It may be due to the patient's last minute doubts and fears. Efforts should be made to improve patient communication and facilitate their compliance with scheduled procedures. Paschoal reported that 54.3% cases of the total cancelled cases were due to absenteeism of the patient because of unawareness of the date of surgery, clinical problems like respiratory tract infections and social/economical reasons 14 .
Disruptions in the power supply has been mentioned as one of the causes of delay in the operation in third world countries 15 .
Cancellations may occurdue toscheduling errors, inadequate preoperative evaluation, inadequate patient preparation, lack of surgical linen,equipment shortage, non-availability of the trained staff etc. This is because of the lackof coordination of different departments involved in the functioning of operating rooms and lack of efficientmanagement ofoperatingtheatrefloor. These reasons are avoidableif proper administrative measures are taken. These cancellations may lead to dissatisfied patients and can be quite costly. Surgicalcancellations could be regarded as adverse events and monitored routinely in hospitalclinicalincidentmonitoringsystems.
Overlapping induction, i.e., induction of anaesthesia with an additional team while the previous patient is stillin the OR has been analyzed and reported to increase the OR productivity by decreasing the nonoperative time by 45.6% 16 . However this requires additional staffand equipmentsthus increasingthe overall cost. However, we can save OR time by inserting epiduralcatheters and peripheral and central intravenous access in the side room prior to shifting the patient to the OR while the previous patient is stillin the OR.
Allstaff concerned with the operating schedule should be punctual to ensure cases are done at planned time. The operating list should be made judiciously. Meticulous care and proper planningmust be taken to complete the OR list daily. It is the duty of the theatrein-charge in consultation with surgeons to ensure that there is no wastage of operating time nor is there overcrowding of the list leading to postponement of surgery. Any postponement of surgery should be justified.
Therequirement of the instruments / drugs/ other equipment necessary for scheduled surgicallist should be discussed among surgeon, staff nurse and the anaesthesiologist a day prior to planned OR list. The non-availability of the surgeon should be informed in time so that another case is substituted in that slot. All patients who have met PACU discharge criteria must be discharged promptly to prevent delay in shifting out of the operated patient. Day care patients should be counseled adequately toreport on time. Computerized schedulingshould be utilized to create a realistic elective schedule. Audit should be carried out at regular intervals to find out the effectivefunctioningof the OR.